Coinsurance – A provision in a member’s coverage that limits the amount of coverage by the plan to a certain percentage, commonly 80%. Any additional costs are paid by the member out of pocket.
Copayment (Co-Pay) – That portion of a claim or medical expense that a member must pay out of pocket. Usually, a fixed amount such as $30.
Deductible – That portion of a subscriber’s (or member’s) health care expenses that must be paid out of pocket before any insurance coverage applies, commonly $1,000-$2,000. May also apply only to one portion of the plan coverage (ex. Radiology services).
Explanation of Benefits (EOB) – A statement mailed to a member or covered insured explaining how and why a claim was or was not paid.
Formulary – A listing of drugs that a physician may prescribe.
Gatekeeper – An informal term that refers to a Primary Care Physician. All care must be authorized by the Primary Care Physician before rendered.
Health Maintenance Organization (HMO) – A licensed health plan (licensed as an HMO) that utilizes designated (usually Primary Care) physicians as gatekeepers.
Member – An individual covered under a managed care health plan. May be either the subscriber or a dependent.
Non Par – Short for nonparticipating. Refers to a physician that does not have a contract with the health plan.
Preferred Provider Organization (PPO) – A plan that contracts with independent providers at a discount for services.
Pre-certification – The process of obtaining certification or authorization from the health plan for a visit to the specialist or for routine hospital admissions.
Primary Care Physician (PCP) – Generally applies to internists, pediatricians, family physicians and general practitioners.
Subscriber – The individual or member who has health plan coverage by virtue of being eligible on his other own behalf rather than as a dependent.